Spontaneous subdural hematoma of arterial origin: report of two cases

Bleeding-Source Exploration in Subdural Hematoma: Observational Study on the Usefulness of Postmortem Computed Tomography Angiography

In a few cases, postmortem computed tomography angiography (PMCTA) is effective in postmortem detection of cortical artery rupture causing subdural hematoma (SDH), which is difficult to detect at autopsy. Here, we explore the usefulness and limitations of PMCTA in detecting the sites of cortical arterial rupture for SDH. In 6 of 10 cases, extravascular leakage of contrast material at nine different places enabled PMCTA to identify cortical arterial rupture. PMCTA did not induce destructive arterial artifacts, which often occur during autopsy. We found that, although not in all cases, PMCTA could show the site of cortical arterial rupture causing subdural hematoma in some cases. This technique is beneficial for cases of SDH autopsy, as it can be performed nondestructively and before destructive artifacts from the autopsy occur.

Detection and Morphological Analysis of Micro-Ruptured Cortical Arteries in Subdural Hematoma: Three-Dimensional Visualization Using the Tissue-Clearing Clear, Unobstructed, Brain/Body Imaging Cocktails and Computational Analysis Method

One of the causes of bleeding in subdural hematoma is cortical artery rupture, which is difficult to detect at autopsy. Therefore, reports of autopsy cases with this condition are limited and hence, the pathogenesis of subdural hematoma remains unclear. Herein, for the detection and morphological analysis of cortical artery ruptures as the bleeding sources of subdural hematoma, we used the tissue-clearing CUBIC (clear, unobstructed, brain/body imaging cocktails and computational analysis) method with light-sheet fluorescence microscopy and reconstructed the two-dimensional and three-dimensional images. Using the CUBIC method, we could clearly visualize and detect cortical artery ruptures that were missed by conventional methods. Indeed, the CUBIC method enables three-dimensional morphological analysis of cortical arteries including the ruptured area, and the creation of cross-sectional two-dimensional images in any direction, which are similar to histopathological images. This highlights the effectiveness of the CUBIC method for subdural hematoma analysis.

The usefulness of postmortem computed tomography angiography for subdural hematoma caused by rupture of the cortical artery: A report of two autopsy cases and a literature review

Acute subdural hematoma (SDH) occurs following severe head trauma with brain contusion or rupture of bridging veins. Conversely, SDH caused by rupture of a cortical artery without trauma or with minor trauma is also possible. Although over 150 cases of the latter SDH have been reported, they were predominantly diagnosed only during surgery, and therefore, no adequate histological evaluation has been performed. Therefore, essential etiology of this SDH type has remained unclear. In addition, the scarcity of autopsy cases may be attributed to arterial rupture being missed if the macroscopic findings are too minimal to detect during autopsy. Here, we describe two autopsy cases of SDH of cortical artery origin. Extravasation on postmortem computed tomography angiography and arterial leakage on macroscopic observation during autopsy facilitated detection of the ruptured artery and allowed detailed histological evaluation of the ruptured artery and adjacent dura mater. The etiology of arterial rupture is briefly described on the basis of histopathological findings in this study and the available literature.

Acute Spontaneous Subdural Hematoma due to Rupture of a Tiny Cortical Arteriovenous Malformation

Acute subdural hematoma (SDH) of arterial origin is rare, especially SDH associated with an arteriovenous malformation (AVM) is extremely rare. The authors report a case of acute spontaneous SDH due to rupture of a tiny cortical AVM. A 51-year-old male presented with sudden onset headache and mentality deterioration without a history of trauma. Brain CT revealed a large volume acute SDH compressing the right cerebral hemisphere with subfalcine and tentorial herniation. Emergency decompressive craniectomy was performed to remove the hematoma and during surgery a small (5 mm sized) conglomerated aciniform mass with two surrounding enlarged vessels was identified on the parietal cortex. After warm saline irrigation of the mass, active bleeding developed from a one of the vessel. The bleeding was stopped by coagulation and the vessels were removed. Histopathological examination confirmed the lesion as an AVM. We concluded that a small cortical AVM existed at this area, and that the cortical AVM had caused the acute SDH. Follow up conventional angiography confirmed the absence of remnant AVM or any other vascular abnormality. This report demonstrates rupture of a cortical AVM is worth considering when a patient presents with non-traumatic SDH without intracerebral hemorrhage or subarachnoid hemorrhage.

Association of subdural hematoma with increased mortality in lobar intracerebral hemorrhage

OBJECTIVE

To determine the prevalence of subdural hematoma (SDH) in patients presenting with primary nontraumatic lobar intracerebral hemorrhage (ICH) and characteristics associated with the presence of SDH.

DESIGN

Retrospective analysis of data collected in a prospective cohort study.

SETTING

Hospital.

PATIENTS

Consecutive sample of 200 patients with primary lobar ICH and 75 patients with deep hemispheric ICH.

MAIN OUTCOME MEASURES

Presence of SDH and mortality.

RESULTS

Subdural hematoma was present in 40 of 200 patients (20%) with primary lobar ICH. By contrast, SDH was not present in any of 75 consecutive patients with deep hemispheric ICH (P < .001 for comparison with lobar ICH). Intracerebral hemorrhage volume higher than 60 cm3 was the only independent predictor of SDH (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.14-6.34; P = .02). Subdural hematoma thickness more than 5 mm was an independent predictor of increased 30-day mortality (OR, 7.60; 95% CI, 1.86-30.99; P = .005) after controlling for other factors including ICH volume. Further analysis showed that the effect of SDH on mortality depended on ICH volume, with larger odds for mortality in those with low ICH volume (OR, 12.85; 95% CI, 2.42-68.23; P = .003 for those with ICH volume <30 cm3). Cerebral amyloid angiopathy was present in 8 of 9 patients with pathological specimens.

CONCLUSIONS

Nontraumatic SDH frequently accompanies primary lobar ICH and is associated with higher 30-day mortality, particularly when the ICH volume is relatively low. Rupture of an amyloid-laden leptomeningeal vessel, with extravasation into the brain parenchyma and subdural space, may be the pathogenic mechanism.

[Brain and head injury. Part 1: Clinical classification, imaging modalities, extra-axial injuries, and contusions]

This article describes the imaging tools for efficient diagnostic management of head trauma victims. The basic mechanisms of brain injuries are explained and the imaging features are described. Computed tomography remains the most important method for the initial screening and follow-up investigation. Though magnetic resonance imaging has a higher sensitivity to most traumatic lesions, it does not play an important role in the acute phase of head trauma patients. In the first part of this paper clinical classifications, imaging modalities, extra-axial injuries, and contusions are described. In the second part of this paper intra-axial and secondary injuries are discussed.

Hematoma subdural agudo espontáneo de origen arterial

INTRODUCTION

An acute subdural hematoma is often regarded as a complication of head trauma. Occasionally subdural bleeding from the rupture of a cerebral aneurysm or an arteriovenous malformations is described. Spontaneous subdural hematoma is, however, very rare and it commonly has an arterial origin and their aetiology is still a matter of controversy.

OBJECTIVE

The purpose of this paper is to present eight cases of spontaneous subdural hematoma seen at our department during the last 19 years. The etiological possibilities of spontaneous subdural hematoma are discussed.

PATIENTS AND METHODS

We analyzed 8 cases of acute spontaneous subdural hematoma among a total number of 321 patients with subdural hematoma is presented.

RESULTS

There were six males and 2 females with a mean age of 52 years (range 20-66). All patients developed progressive neurological deficits, until become comatose. All eight patients were operated on and surgical mortality was 25%.

CONCLUSIONS

Spontaneous subdural hematoma is a rare condition and the prognosis is mainly dependent on the pre-operative neurological state regardless of its origin or cause.

Acute subdural hematomas due to rupture of cortical arteries: a study of the points of rupture in 19 cases

BACKGROUND

Several cases of acute subdural hematomas (ASDHs) due to rupture of cortical arteries are reported. They have several characteristic features: (1) their outcome is relatively good; (2) the cause is a trivial head injury; (3) patients are elderly; (4) a lucid interval is recognized; (5) hypertension is associated in many cases; and (6) cerebral contusion is absent. However, there has been no report about the points of rupture in the cortical arteries.

METHODS

In 19 of the 125 patients with ASDHs admitted to our department, the cause of ASDH was bleeding from cortical arteries. The bleeding points were detected at surgery. Cases associated with cerebral contusion during or after the operation were excluded. In this article, we describe the clinical findings and the sites of bleeding from arteries in 19 cases of ASDH due to rupture of cortical arteries.

RESULTS

The sites of ruptured arteries were as follows: prefrontal artery in one of 23 identified arteries (4.3%); precentral artery in five (21.7%); central artery in four (17.3%); anterior parietal artery in four (17.3%); angular artery in three (13.0%); middle temporal artery in four (17.3%); and posterior temporal artery in two arteries (8.7%). Two ruptured arteries in the same craniotomy were observed in four patients (17.3%). All points of rupture were located near the sylvian fissure (within 3 cm length around the sylvian fissure) and none in the base or vertex of the brain.

CONCLUSION

If an ASDH occurs following a trivial head injury, rupture of cortical arteries should be considered as a possible cause. Wide craniotomy sufficiently covering the region surrounding the sylvian fissure should be performed to obtain hemostasis of bleeding points.

Spontaneous acute subdural hematoma precipitated by cocaine abuse: case report

A novel complication of the illicit use of cocaine, a spontaneous acute subdural hematoma, is described. This case represents another addition to the growing literature on the negative effects of cocaine on the central nervous system. Photographic documentation of the lesion responsible for the hematoma is presented, along with a discussion of the possible pathophysiologic mechanism.

Acute spontaneous subdural hematoma of arterial origin: a report of five cases

Acute spontaneous subdural hematoma of arterial origin is very rare. We report five patients who presented with a history of sudden onset of severe headache and vomiting and who developed progressive neurologic deficits, three becoming comatose. The symptomatologic onset was indistinguishable from other cerebrovascular disorders; none of the patients had a history of head trauma. In all our patients, the source of bleeding was identified at operation as a cortical artery located near the Sylvian region. Comparable cases in the literature are reviewed and the etiologic possibilities are discussed.

Acute subdural haematoma from ruptured intracranial aneurysms

Acute subdural haematoma (SDH) secondary to a ruptured intracranial aneurysm is a rare event. Out of a total of 292 patients with a verified aneurysm (period 1986-1992) in five cases SDH was the diagnosis on CT-evaluation. One patient was in such a bad condition that no treatment was indicated. The remaining four patients were operated on: craniotomy and haematoma evacuation in two cases, craniotomy for haematoma evacuation and aneurysm clipping in the other two cases. Two patients died and two achieved a good outcome.

Angiographic extravasation of contrast medium in acute "spontaneous" subdural hematoma

Acute spontaneous subdural hematoma is very rare. We have encountered four such cases and verified the arterial origin of the bleeding at operation. None of the patients had a history of head trauma, and each had developed sudden onset of headache and other neurologic deficits, which simulate other cerebrovascular diseases. CT directly revealed subdural hematoma but gave no indication as to the source of the bleeding. Cerebral angiography was performed in all cases, with three of them showing localized extravasation of the contrast material into the subdural space. The extravasation was noted usually in the late arterial phase. This is a useful finding for diagnosing this disease and localizing the bleeding point. It is expected that with more routine use of cerebral angiography in cases of acute spontaneous subdural hematoma, extravasation of the contrast medium will be seen more frequently.

Pure subdural haematomas of arteriolar origin

Fifteen consecutive cases of subdural haematomas (SDHs) of arteriolar origin operated on during the last twenty years in the Neurosurgical Clinic of the University of Genoa are reported. These SDHs are rare and form as a result of a rupture of a cortical arteriolar branch typically on the vicinity of the Sylvian fissure. They are always in a pure form and never associated with parenchymal lesions. Their aetiology is spontaneous, as in the 40% of our series, or more frequently related to minor traumas. These SDHs are often encountered in elderly patients generally presenting with severe clinical conditions (in the 60% of our patients GCS on admission was < 8). Prompt surgical treatment is required in all cases before further worsening of their neurological condition, even if CT scanning does not reveal parenchymal lesions. The mortality rate is over 50% and mainly relates to the pre-operative GC score. Clinical features, neuroradiological aspects and treatment are discussed and literature reviewed.

Acute spontaneous subdural hematoma in a teenager

A teenager with a history of sudden onset of headache and vomiting is described. Computed tomography revealed an acute subdural hematoma in the right temporoparietal region, causing marked compression of the right ventricular system and a shift of midline structures to the left. No operation was carried out because the symptoms and neurological signs were slight enough to allow monitoring by means of close clinical and neuroradiological investigations. Within 18 days the hematoma resolved spontaneously and completely. There was no history of trauma or any objective sign of trauma about the face or head, and radiography of the skull showed no fracture. We are not aware of any other report of a spontaneous subdural hematoma which did not require surgery. This feature makes our case unique. In addition, comparable cases in the literature are reviewed and the etiological possibilities of spontaneous subdural hematoma are discussed.

Changes in CSF pressures during experimental acute arterial subdural bleeding in pig

The effects of acute arterial subdural bleeding on cerebrospinal fluid (CSF) pressure and 12 other vital parameters were studied in spontaneously breathing pigs (group 1, n = 9) and in mechanically ventilated pigs (group 2, n = 18) to analyze quantitatively the bleeding course and the lethal mechanism. Spontaneously breathing animals all succumbed after a mean bleeding volume of 45.6 +/- 8.9 ml, corresponding to about 50 per cent of the intracranial volume, and a mean bleeding duration of 11.0 +/- 2.6 min. Rapid rise in CSF pressures, marked transtentorial pressure gradients, and progressive reductions of cerebral perfusion pressure leading to a permanently iso-electric EEG, apnoea and to a terminal rise in arterial pressure (Cushing response), was the rule in these animals. The mechanically ventilated animals had smaller bleeding volumes (34.3 +/- 8.1 ml), but longer bleeding durations (13.8 +/- 5.8 min). In this group 7 animals survived. They had no pressure gradients, and only moderate changes in arterial pressure and EEG. The 11 animals that succumbed had marked transtentorial pressure gradients, but smaller increments in arterial pressure than the spontaneously breathing animals. At autopsy, subdurally located blood was found throughout the intracranial and spinal subdural compartments and along the spinal nerve roots in both groups. The results of this study suggest that survival after acute subdural haematoma is influenced by the presence of transtentorial pressure gradients and by the spinal sac acting as a space for expansion. The beneficial effect of artificial ventilation is discussed.

[Acute intracranial subdural hematoma of arterial origin after spinal anesthesia]

A case of an acute intracranial subdural haematoma occurring shortly after spinal anaesthesia is reported. A 67 year old poorly controlled hypertensive man, ASA II, underwent removal of a prostatic adenoma under spinal anaesthesia. He complained of postural headache on the third day after surgery. Unresponsive to the usual analgesics, his headache became severe, persistent and non postural on the fifth day. Twenty-four hours later, he suddenly presented with a left hemiplegia and became comatose. Computed axial tomography showed a large left-sided subdural haematoma, lying over the left hemisphere. During the immediate surgical removal, a pulsatile arterial bleeding originating from a small cortical artery was discovered, and stopped. The patient slowly recovered consciousness, but the hemiplegia remained. He finally died six months later of bronchopneumonia. The link between the haematoma and the spinal anaesthetic is not proven; the possible relationship between the two is discussed.

Acute spontaneous subdural hematoma of arterial origin

Acute spontaneous subdural hematoma of arterial origin is very rare. We have encountered two such cases and verified the arterial origin of the bleeding at operation. Both patients had no history of head trauma and developed progressive neurological deficits, becoming comatose. The source of bleeding was identified as a cortical artery located on the temporal lobe near the Sylvian region. This type of lesion is reviewed in the literature and the etiology is discussed.

Acute spontaneous subdural hematoma of arterial origin

A patient is described who had a history of sudden vomiting and rapidly becoming deeply unconscious. There was no history of head trauma. The cause turned out to be an acute spontaneous subdural hematoma from arterial rupture. Comparable cases in the literature are reviewed and the etiological possibilities are discussed.

Acute spontaneous subdural hematoma

A review of the literature reveals 20 reported cases of acute spontaneous subdural hematoma. We present an additional case with a tabulation of pertinent data. The prototype case is described, emphasizing the benign and insidious onset followed, invariably, by a deteriorating neurological status leading, almost always, to surgical evacuation. A high index of suspicion for this entity is of great importance, because a delay in diagnosis may lead to an increase in the morbidity and the mortality of this condition.

Acute hypertensive subdural hematoma from arterial rupture shortly after the onset of cerebral subcortical hemorrhage: leakage of contrast medium during angiography

A case is reported of a Japanese female in whom acute right subdural hematoma due to the spontaneous rupture of the posterior branch of the right central artery occurred shortly after the onset of hypertensive subcortical hemorrhage of the right occipital lobe. Marked hypertension persisted. There was no evidence of subdural hematoma when a small collection of extravasated contrast medium from the cortical artery was revealed during right carotid angiography. Soon thereafter the patient became comatose and developed decerebrate posturing. Computed tomography scan was done immediately and a large subdural hematoma was identified. There was a gratifying response to prompt recognition and neurosurgical therapy of the condition. The pinpoint rupture of the cortical artery is considered to have occurred during marked hypertension. Previous 39 cases with subdural hematomas from arterial rupture, 27 traumatic and 12 spontaneous nontraumatic, are reviewed.

Superior sagittal sinus thrombosis followed by subdural hematoma

A case of superior sagittal sinus thrombosis followed by a subdrual hematoma is reported. A 33-year-old woman, who presented with serious neurological deficits, made a remarkable recovery with mild residual. She had a thin subdural fluid collection, which eventually developed into a subdural hematoma. After evacuation of the hematoma, she had no neurological deficits. Treatment of cerebral venous and dural sinus thrombosis is discussed.

Acute subdural hematoma. Review of 39 consecutive cases with high incidence of cortical artery rupture

In a consecutive series of 39 cases of acute subdural hematoma (SDH), encountered since computerized tomography diagnosis became available, 61.5% were found to be the result of bleeding from a small cortical artery, 25.6% were of venous origin, 7.7% resulted from cerebral contusions, and 5% were acute bleeds into chronic subdural hematomas. Craniotomy was performed promptly on admission, but there was no difference in survival (overall 51.3%) between patients with arterial and venous bleeds. The only apparent factor affecting survival in this series was the preoperative neurological status: 67% of patients who were decerebrate and had fixed pupils prior to operation died. Of patients with less severe neurological dysfunction, only 20% failed to survive.